Download the decision making business case for hyper acute stroke services

314 Pages·2017·5.28 MB·English

by  Jane Anthony

ENCLOSURE B

Cover Paper – Decision Making Business Case for the Reconfiguration of Hyper Acute
Stroke Services

JOINT COMMITTEE OF CLINICAL COMMISSIONING GROUPS

15th November 2017

Author(s) Marianna Hargreaves, Transformation Programme Lead, SYB Accountable
Care System
Lisa Wilkins, Consultant in Public Health Medicine, SYB Accountable Care
System and Barnsley CCG
Jeremy Cook, Director of Finance, SYB Accountable Care System
Sponsor Lesley Smith - System Reform Lead, SYB Accountable Care System
Will Cleary-Gray – Sustainability and Transformation Director, SYB
Accountable Care System
Is your report for Approval / Consideration / Noting

For consideration for onward approval

Are there any resource implications (including Financial, Staffing etc)?

Outlined in the decision making business case.

Summary of key issues

 Enclosed is the final decision making business case for the reconfiguration of hyper
acute stroke services in South Yorkshire and Bassetlaw Accountable Care System
(SYB ACS).

 The business case has an Executive Summary that sets out clearly the case for
change, proposed new model, anticipated benefits, risks and mitigation plans and
financial implications.

 Its purpose is to enable the Joint Committee of Clinical Commissioning Groups to
make an informed decision on the reconfiguration of hyper acute stroke services in
the SYB ACS.

 The new model it proposes for SYB ACS will enable us to provide a resilient,
sustainable hyper acute stroke service that secures improved health outcomes for
SYB patients.

 The business case has been assured by NHSE who are supportive of the proposed
clinical model and governance arrangements.

 It is also supported by NHS England Specialised Commissioning.

Recommendations

The Joint Committee of Clinical Commissioning Groups is asked to consider all the
information set out in the decision making business case and approve the recommended
new model of hyper acute stroke care for SYB ACS.
By approving this business case Clinical Commissioning Groups are agreeing to fund the
new model of hyper acute stroke care.
Working Together Programme
Decision Making Business Case
For
Hyper Acute Stroke Services

November 2017

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Document Control

Title Business Case for Reconfiguration of Hyper Acute Stroke Services
Authors Marianna Hargreaves – Transformation Programme Lead, South Yorkshire
& Bassetlaw Accountable Care System
Lisa Wilkins – Consultant in Public Health Medicine, South Yorkshire &
Bassetlaw Accountable Care System
Jeremy Cook – Interim Director of Finance, South Yorkshire & Bassetlaw
Accountable Care System
Rachel Gillott – Programme Director Urgent and Emergency Care, South
Yorkshire & Bassetlaw Accountable Care System
Target Audience Joint Committee of Clinical Commissioning Groups
Version V 0.19
WTP Reference HASU DMBC
Created Date March 2017
Date of Issue November 2017
Document Status Final Draft
To be read in
conjunction with See section 2
File name and path
Document History:
Date Version Author Details
From 10/03/2017 to V0.0 Rachel Gillott Document created, expanded, updated and
to V0.14 Chris Taylor refreshed. Inclusion of procurement section
31/03/2017 & travel impact summary and circulation to
Chief Officers.
4/04/2017 V0.15 Marianna Further consolidation & amendments post
Hargreaves Chief Officer review.

15/05/2017 V0.16 Chris Taylor Adding in links and general formatting.

19/05/2017 V0.17 Marianna Refresh and expansion of the proposed
Hargreaves model, updated finance section and
Jeremy Cook conclusion.
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22/08/2017 V0.18 Marianna Further additions - New Executive
Hargreaves Summary, context, learning from
Lisa Wilkins Manchester and developed details of the
Jeremy Cook proposed model, anticipated benefits,
risks and mitigation plans & finances
06/11/2017 V0.19 Marianna Minor amendments as directed by NHS
Hargreaves England feedback.
Jeremy Cook
Approval by: Joint Committee of Clinical Commissioning Groups
Governance route:
Group Date Version Purpose
CCG Chief Officers 3rd April 2017 V0.14 Review and comments
Joint Committee of
Clinical Commissioning 24th May 2017 V0.17
Groups
Joint Committee of
Clinical Commissioning 18th October 2017 V0.18 Review and feedback
Groups
NHS England
Assurance 1st November V0.18 Assurance review
2017

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Contents

Page number
1. Executive Summary 7
1.1 Purpose 7
1.2 New Context 8
1.3 Scope 8
1.4 National Policy Context & Guidance 9
1.5 Summary of the Case for Change 9
1.5.1 Evidence 10
1.5.2 Current Variation in Quality – Scope to improve care 10
1.5.3 Workforce Challenges 11
1.5.4 Clinical & Cost Effectiveness 11
1.5.5 Demographics 12
1.6 The Review, Options, Appraisal and Preferred Option 12
1.7 Public Consultation 14
1.8 The Proposed Model 14
1.8.1 Development of a Stroke Managed Clinical Network (MCN) 15
1.8.2 Consolidation of Hyper Acute Stroke Care 15
1.8.3 Mechanical thrombectomy 19
1.8.4 Stroke Mimics 19
1.8.5 New Patient Flows 19
1.8.6 Phasing of Implementation 20
1.9 Anticipated Benefits, Risk and Mitigation Plans 21
1.9.1 Anticipated Benefits 21
1.9.2 Risks and Mitigation Plans 22
1.9.3 Anticipated Benefits, Risks and Mitigation Plans - Summary 25
1.10 Financial, Contractual and Procurement Implications 25
1.10.1 Finance 25
1.10.2 Contractual 26
1.10.3 Procurement 26
1.11 Recommendation 26
2. Purpose, New Context and Background 27
2.1 Purpose 27
2.2 New Context 29
2.3 Background 31
2.3.1 Commissioners Working Together: Hyper Acute Stroke 31
Service Review
2.3.2 Definitions 32
2.3.3 Scope 35
3. The Case for Change 35
3.1 National Context 35
3.2 National Policy and Guidance 35
3.3 National Evidence 37
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3.4 Evidence and Learning from HASU Models: Greater 41
Manchester and London
3.5 Drivers for Change in South Yorkshire & Bassetlaw 44
3.5.1 Variation in Quality of Current Provision (SSNAP) 44
3.5.2 Workforce Challenges 51
3.5.3 Sustainability of provision – Clinical & Cost Effectiveness 52
3.5.4 Demographics 52

4. Options 54
4.1 High level options appraisal 54
4.2 Stage 1 Options Appraisal 54
4.3 Stage 2 Options Appraisal – Y&H Blueprint 55
4.4 Stage 3 Options 57
4.5 Options Assessment Criteria 57
4.6 Preferred Option 60

5. Communication and Engagement including Public Consultation 61
5.1 Method and approach 61
5.2 Key themes emerging throughout the pre-consultation 63
5.3 Clinical engagement 64
5.4 Travel Impact Analysis 64
5.5 Public Consultation 64
5.6 Channels we used to communicate about the consultation 65
5.7 Communication and engagement activities undertaken 65
5.8 What response did we get? 66
5.9 Consultation survey response 66
5.10 What did respondents say? 67
5.11 Written submissions 72
5.12 Meetings 73
5.13 Concluding comments 75

6. Proposed Model
6.1 Outline of the proposed model 77
6.2 Development of a Stroke Managed Clinical Network 77
(MCN)
6.3 Consolidation of hyper acute stroke care 78
6.4 Workforce requirements and opportunities 85
6.5 Phasing of implementation 85
6.6 Mechanical thrombectomy 86
6.7 Stroke mimics 87
6.8 New patient flows 89

7. Anticipated Benefits, Risks and Mitigation Plans 94
7.1 Anticipated Benefits 94
7.2 Risks and Mitigation Plans 99

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8. Finance, Commissioning and Procurement 109
8.1 Finance 109
8.1.1 Current National Funding Model 109
8.1.2 Process 109
8.1.3 Activity data - Confirmed Strokes 110
8.1.4 Stroke Mimics 112
8.1.5 Financial envelope 112
8.1.6 Transportation 114
8.1.7 Local Tariff Funding Model 114
8.1.8 Financial Implications for Commissioners and Providers 115
8.1.9 Phasing of implementation 121
8.1.10 Mitigation of risks 121
8.2 Commissioning & Contracting 123
8.2.1 Commissioning Arrangements 123
8.2.2 Procurement and Contract Award 124
8.2.2.1 Procurement 124
8.2.2.2 Contracting 124

9. Mobilising the Preferred Service Delivery Model 126
9.1 HASU Service Specification Development 126
9.2 Mobilisation 126

10 Equality Impact Assessment 130
11 Conclusion 133
12 Recommendations 136

Appendix A Key elements of the stroke pathway
Appendix B Guidance for Sustainability and Transformation
Partnerships on the recommended standards for acute
stroke services
Appendix C Independent Analysis, Full Report Public Consultation
Appendix D Details of all the organisations involved in the review of
hyper acute stroke services
Appendix E Steps in hyper acute pathway, relevant standards and
implications for a centralised or non centralised HASU
model
Appendix F Stroke Sentinel National Audit Programme – Further
details of domains relating to hyper acute stroke care
Appendix G Procurement discussion paper
Appendix H Equality Impact Assessment

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1. Executive Summary

1.1 Purpose

The purpose of this business case is to

 Enable a decision to be made on the future model of hyper acute stroke
services across the South Yorkshire and Bassetlaw Accountable Care System
(SYB ACS) formerly the Commissioners Working Together footprint.

 Propose a new hyper acute stroke service model for the SYB ACS that will
provide a resilient, sustainable service that secures improved health
outcomes for patients across South Yorkshire and Bassetlaw.

1.2 New Context

 The current provision of hyper acute stroke care at Rotherham and Barnsley
hospitals is becoming increasingly fragile. Both services are now reliant on
the use of locums and Barnsley Hospital is redirecting patients for
thrombolysis to other hospitals, including Pinderfields in Wakefield.

 In the proposed new model hyper acute stroke care for SYB ACS patients will
be provided in Sheffield, Doncaster and Wakefield. Patients who would
previously have received hyper acute stroke care in Rotherham and Barnsley
Hospitals will in future receive it at one of the above hospitals. Hyper acute
stroke care will also continue in Chesterfield.

 There is a significant risk that not progressing the new model, (doing nothing)
will result in increasing challenges for the already fragile services in
Rotherham and Barnsley hospitals and potential deterioration in the quality
and safety of the provision.

 In addition to the increasing operational challenges, the strategic context
within which this business case is presented is significantly different to that at
the outset of the review of hyper acute stroke services.

 South Yorkshire and Bassetlaw is now a shadow Accountable Care System
(SYB ACS) and is working together with local, regional and national partners
to develop as a full Accountable Care System from April 2018. As such, it
recognised nationally for its strong and effective relationships and leadership
and its focus on delivering improved care and services for local populations. It
builds on our previous collaborative work both in ‘Place’, developing
integrated local health and care and across the whole ACS including the
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acute vanguard collaboration of acute hospitals. It is expected that it will work
as a locally integrated system, with provider organisations operating on a
horizontally integrated basis through clinically networked services. This
business case proposes a managed clinical network for stroke care which
starts to build on networked services across the ACS.

 The SYB ACS will have increased control over the total operations of the local
health system, including managing the funding for the population with an
agreed ‘control total’ across all organisations. It is within this context that the
business case for the reconfiguration of hyper acute stroke care is presented.

 The SYB ACS has initiated a Hospital Services Review (HSR) and stroke care
has been identified as an area of focus following the outcome of the rigorous
methodology. It has been acknowledged that the proposal to reconfigure
hyper acute stroke is to enable us to secure sustainable and resilient hyper
acute stroke care, but that this alone will not resolve all the sustainability
issues for stroke and hence the inclusion of stroke care within the HSR.

 The Joint Committee of Clinical Commissioning Groups endorsed principles in
September to further inform the business case, these identified that;

o To secure improved quality and outcomes for patients who have had a
stroke, it will require commissioners to invest additional resources
(above the increase already seen through the move from HRG4 to
HRG4+ tariffs), through the best practice tariff.
o The stroke tariff would need to be ‘split’ to cover hyper acute stroke
care and acute stroke care/inpatient stroke rehabilitation.
o An informed decision on the reconfiguration of hyper acute stroke care
would progress ahead of the Hospital Services Review (HSR) and the
HSR would proceed with a whole pathway approach (recognising the
learning from other parts of the country where improvement have been
made to stroke care and outcomes as a result of new models and the
importance of making a decision on the hyper acute at the outset).
o The expectation is that the recommendations of the whole Hospital
Services Review will be cost neutral overall. This is an agreed principle
underpinning the SYB HSR.

1.3 Scope

 The scope of this business case is the ‘hyper acute phase’ of the stroke
pathway, considered to be, on average, the first 72 hours of treatment.
See figure 1. For more details of the stroke pathway see appendix A

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